Universal Problems _ Universal Healthcare.pdf by lovemacromastia


									                                                                                                                                                   FORU M
                                            Medical Errors in Canada:
                                     A Sideways Glance at a Universal Problem
    In the Oregon’s Future Spring 2004            one in 13 patients (7.5 percent) treat-      can be accessed by all health-care
    Forum, we discussed medical errors            ed in Canadian hospitals will experi-        providers—a problem the US system
    in the US and Oregon—but this is              ence an adverse event such as a surgi-       also faces. In fact, the percentage of
    not just a US problem. In May of              cal error or complications because of        hospitals who have invested in this
    2004, The Canadian Adverse Events             an incorrectly prescribed drug. Dr.          type of health information technology
    Study revealed that adverse events in         Peter Norton, co-author of the study,        in both countries is about 15 percent.
    Canadian hospitals cause between              believes the number of adverse
    9,000 and 24,000 deaths a year. The           events may be underestimated.                Authors of the report concluded that
    Canada Institute for Health                   Compared to Australia, Britain, and          of the almost 2.5 million annual hos-
    Information extrapolated that non-            New Zealand studies, Canadian med-           pital admissions in Canada, about
    lethal adverse events cause Canadians         ical error rates are lower. But when         185,000 are associated with a medical
    to spend more than one million extra          compared to similar studies in US            error and that close to 70,000 are
    days in the hospital. The Canadian            hospitals, Canadian care givers com-         probably preventable. The Canadian
    press reported this figure as the same        mit twice as many errors. Critics            Institute for Health Information’s web
    amount of hospital beds needed to             blame poor communication among               site provides the complete results of
    care for every woman in Canada                different tiers of care, from doctors        the study and a comparison of
    experiencing pregnancy and childbirth         and nurses to pharmacists.                   methodologies used in studies in the
    at the same time.                             Healthcare officials and the press in        US and developed countries with uni-
                                                  Canada discuss the fact that hospitals       versal healthcare systems.
    The report surprised health officials         have not invested in computer-based
    all over Canada and projected that            charts and patient health records that       Jay Hutchins

 Universal Problems &
                                                                                                              may be culturally an anathema,
                                                                                                              whether it is the restrictions on
                                                                                                              private insurers in Canada, the
                                                                                                              government established physician

 Universal Healthcare:                                                                                        fee schedules in France, or
                                                                                                              compulsory social insurance in
                                                                                                              Switzerland. The point to note
                                                                                                              is that each country has found a
 6 C O U N T R I E S — 6 S YS T E M S                                                                         model of universal coverage that
                                                                                                              conforms to the country’s cultural
                                                                                                              and political norms and that sin-
                                     by Albert DiPiero, MD, MPH                                               gle payer is not the only path to
                                                                                                              accomplishing universal coverage.

    THE UNITED STATES IS THE         functioning in these countries     as the United States. Despite              Canada—Medicare
only modern, industrialized          at a fraction of the spending      these differences, there is no             Canada provides lifetime
nation without some version of       seen today in the United States.   evidence to suggest that our          health insurance to all its resi-
universal access to healthcare       On a per capita basis, the         level of spending helps us            dents through a publicly funded
services. All other industrialized   next biggest spender after the     achieve the superior health           health insurance plan adminis-
countries have addressed the         United States is Switzerland,      status of the Canadians,              tered independently by each
policy and the financial chal-       which spends only 68 percent as    Japanese and Europeans.               province (Provincial Health
lenges of universal access           much. Canada and the United             Each of these systems has        Plan). There is no link between
through a wide variety of meth-      Kingdom spend 57 percent and       elements that may be attractive to    health insurance and employ-
ods. Universal healthcare is         44 percent as much per capita      Americans but also elements that      ment, so insurance is permanent

Fall 2004                                                                                                                                    27
                                                          Oregon’s Future
FORU M   Healthcare                                                                    In Britain, unlike the
                                                                                       United States there
         and fully portable. The Canadian     through the National Health               is no link between                  ists and the Primary Care Trusts
         system is the prototypical single
         payer system. This is the ulti-
                                              Service (NHS), which began in
                                              1948 on a vision of universal,
                                                                                         employment and                     will have incentives to manage
                                                                                                                            within their budgets and coordi-
         mate use of pooling: everyone in     comprehensive, free care for the           health insurance.                  nate care for the benefit of the
         the province is covered by one       entire population. The British                                                local communities. To improve
         insurance plan and each              system is founded on the concept      ical centralized, command-and-          the quality and transparency of
                                              of society fulfilling an obligation   control socialized system. It can-      the system physician pay will now
           In Canada private                  for maintaining the health of its     not be driven by consumer               be based on 76 quality indicators
                                              people. The NHS is funded             demand beyond the budget.               ranging from medical records to
            insurance is not                  mainly through national tax           However, the NHS has gone               outcomes such as achieving cho-
         permitted for services               financing. Unlike in the United       through periodic reforms that           lesterol levels based on national
                                              States, there is no link between      swing between centralization            guidelines. The results of these
             covered by the                   employment and health insurance       and devolution of responsibility        initiatives represent the most
         Provincial Health Plan.              within the NHS, so access to          to the periphery.                       extensive reforms in the history
                                              healthcare is universal, lifelong,          Currently, under the Labor        of the NHS and will be followed
         Provincial Health Plan serves as     and fully portable. However,          government of Tony Blair,               closely by all nations.
         the one payer of healthcare ser-     Britain does permit coexisting        reforms are again emphasizing
         vices in each province. Private      private health insurers to provide    localism and also consumer-ori-                      France
         insurance is not permitted for       insurance that covers the same        ented service. Under recent                  The French healthcare sys-
         services covered by the              services as the NHS. Physicians       reforms, general practitioners are      tem was rated number 1 in the
         Provincial Health Plan. (Please      are either general practitioners,     part of Primary Care Trusts whose       world by the World Health
         see Mark Kaplan’s Myths and          who are paid by either capitation     governing bodies are elected            Organization in 2000. The French
         Realities of the Canadian            or salary, or specialists who are     locally to foster local accountabili-   system is based on a philosophy of
         Medicare in this issue of            salaried employees of the NHS.        ty. Primary Care Trusts receive a       solidarity (universal access to
         Oregon’s Future —JH)                 Specialists, however, may perform     budget based on uniform national        healthcare) and liberalism also
                                              part-time private practice work       prices for conditions and proce-        known as market-based pluralism.
                United Kingdom—               outside of the NHS to supple-         dures and commission services           (Implies choice that fosters experi-
              National Health Service         ment their incomes. The NHS is        from specialists and hospitals.         mentation —Ed.) Everyone is cov-
              Great Britain takes a differ-   usually portrayed as the prototyp-    Patients will choose their special-     ered by national health insurance
         ent path to universal healthcare.                                                                                  (NHI), which is mandatory—no
         In Britain, healthcare is provided

         28                                                                                                                                          Fall 2004
                                                                     Oregon’s Future
                                                                                                                                                        FORU M
                                       The French healthcare                                                                     Healthcare
                                         system has similar
one may opt out. People are auto-        problems to other                   ing population that values            People can choose among any of
matically enrolled in an insurance      modern countries.                    high technology medical care,         the nonprofit social insurance
fund based on occupational status.                                           Switzerland may provide some          funds or private insurers that
In France universal coverage was                                             lessons for the United States.        operate in the canton. Because
achieved in incremental steps          co, alcohol, pharmaceuticals, etc).         The Swiss system is charac-     of the uniformity of the benefits,
with all residents finally covered     The NHI accounts for 76% of           terized by a mix of public and        insurers compete on price and
in 2000. Patients pay for outpa-       healthcare expenditures and sup- private financing and public and           quality of service.
tient care directly and are then       plemental private insurance and       private healthcare delivery orga-          There is no variation in pre-
reimbursed by the NHI. There is        out-of-pocket expenses cover          nizations, a high degree of choice    mium within an insurer based on
co-insurance but no deductibles        12% and 11% respectively.             and responsiveness to patient         medical status, age or gender. But
and patients suffering from chron-           The French health system        desires, and a decentralized regu-    there are significant differences
ic illnesses are exempted from         receives high satisfaction marks      latory system. This mirrors the       in the price of the basic package
payments. In addition to NHI,          from the population and is among Swiss political system, which is a         between insurers. Premiums are
90% of the population obtains          the world leaders in measures of      confederation of 23 cantons. The      not income adjusted. But the sys-
supplemental insurance to cover        population health status. This is     federal government’s legislative      tem enables access to the insur-
other benefits and perks.              accomplished with per capita          power is limited to what is grant-    ance market for everyone by pro-
       The French system is            spending at 52% of the level in       ed by the cantons and healthcare      viding tax-financed subsidies so
diverse and delivers great free-       the United States.                    regulation, financing, disease        that no individual spends more
dom to the patient and the                   The French healthcare sys-      prevention and education takes        than 10% of income on health
providers. Outpatient providers        tem has similar problems to other place at the cantonal level.              insurance premiums. Cost-sharing
are predominantly independent          modern countries. In the May                Switzerland spends 68 per-      exists in the form of deductibles
solo practitioners, operating pri-     2004 edition of the Christian         cent of what the United States        and co-insurance, with out-of-
vate practices and are reimbursed      Science Monitor Peter Ford            spends per capita on healthcare       pocket expense limits set by the
fee-for-service. The fee is based      reports the 15 billion dollar deficit and dedicates 11.1 percent of         federal government.
on a national fee schedule set         the system created this year.         its GDP to healthcare. In terms            Within each canton, the
by the NHI. The fees are tightly       Reforms being discussed in            of per capita spending on health-     insurers collectively negotiate
restrained and are the main            France include the same reforms care and as a percentage of                 fees with the service providers,
method of cost control. As a           discussed in other nations with
result, average physician income
is one-third the level of U.S.
                                       and without universal healthcare
                                       systems: computerizing patient
                                                                                    On a per capita basis, the next biggest
physicians. However, certain           records, encouraging patients to               spending after the United States is
physicians—mainly specialists—
are given the right to bill the
                                       visit their family doctors before
                                       going to expensive specialists,
                                                                                  Switzerland, which spends only 68 percent
patient extra for services. Patients   boosting the use of cheaper                  as much, while Canada and the United
can see any physician they
choose without referral. French
                                       generic drugs, and making
                                       patients pay a nominal charge for
                                                                                  Kingdom spend 57 percent and 44 percent
hospitals consist of public hospi-     each visit to a doctor. Ford’s arti-        as much per capita as the United States.
tals and private proprietary hospi-    cle reports that a French govern-
tals. In fact, proprietary hospitals   ment study earlier this year found GDP, Switzerland is second               including hospitals and physi-
make up a greater portion of hos-      that the French take nearly four      only to the US.                       cians. Health insurers end up
pital beds in France than in the       times more tranquilizers than               In contrast to insurance in     directly paying for 48% of annual
United States. Proprietary hospi-      their neighbors, and that 350 peo- France, Germany and the United           healthcare expenditures, private
tals are paid a per diem rate          ple a day are hospitalized due to     States, health insurance in           households pay for 24%, cantons
negotiated with the NHI while          toxic interactions between pre-       Switzerland was always individual     and local governments pay for
public hospitals are reimbursed        scription drugs. (Health Minister     insurance, with no link to            15% and old age and disability
via a global budget. The NHI           Philippe Douste-Blazy told a par- employment or profession or               and accident insurance pays for
sets the allowable reimbursable        liamentary commission “Profound class. The system also guarantees           the rest.
prices for prescription drugs.         reforms are urgent.”)                 that the poor have access to the           In addition to Compulsory
       The NHI funding comes                                                 same system as the rest of the        Basic Social Insurance, the Swiss
from employer and employee                         Switzerland               population. All insurers must offer   have access to supplemental
payroll taxes, a general tax on all          As a democracy with an          the basic benefit package and are     insurance, which may be provided
earnings and special taxes (tobac-     advanced economy and a demand- required to accept all applicants.           through the social insurance

Fall 2004                                                                                                                                         29
                                                              Oregon’s Future
FORU M   Healthcare

         funds or private for-profit insur-    experts point out the lack of         1993. In 1993, the NHI bill was       for the care of major illnesses and
         ers. Supplementary insurance          incentives for either providers or    submitted to Parliament and           preventive services. Yearly caps
         is not considered necessary to        patients to seek out efficient,       passed on July 19, 1994. Providers    on the cost sharing exist, but crit-
         receive excellent care.               high value care. The system con-      and the public anticipated a          ics complain that the cost sharing
               Healthcare is delivered by      tains the elements of market          gradual implementation.               is regressive falling proportionally
         private office-based physicians       competition, such as multiple               Then in a bold move pre-        greater on the sick and poor.
         paid fee-for-service and by           insurers and private sector           empting political opponents,          Patients have full freedom to go
         salaried physicians who are hospi-    providers and hospitals, but the      President Lee Teng-Hui                to any provider or hospital of their
         tal employees. The outpatient-        reality has been a focus on patient   announced that the NHI would          choice and treatments are com-
         based physicians are organized        choice rather than true market        go live on March 1, 1995. The         pletely left in the hands of
         into medical associations. For the    competition. The debate now           Public quickly supported the pro-     providers and patients. There
         patient there is complete freedom     centers on either a path of greater   gram, which took only 8 months        is no explicit rationing of care,
         of choice of physicians.              government centralization or          to implement. NHI is a single         no waiting lists and no referral
               Hospitals are public or pri-    more open price and quality com-      payer system that makes use           requirements.
         vate, nonprofit or for-profit and     petition with safeguards for the      of the power of pooling: every              The result has been a rapid
         must be on the list of the accept-    poor. Either path will challenge      Taiwanese must enroll and must        expansion in medical system uti-
         ed hospitals in a canton to be        the Swiss population to face the      contribute. Today 96% of the          lization with evidence of over
         reimbursed by the social insur-       costs of their deep belief in uni-    population participates.              treatment, low quality care, and
         ance funds. Both the federal gov-     versal access to technologically            The NHI is administered by      over capacity. The perception
         ernment and the canton provide        advanced healthcare with no           a single government department        among providers is that the set
         subsides to hospitals. This has       explicit rationing.                   that is financed through premi-       fees are too low. And so, in a fee-
         led to a large capacity of hospital                                         ums and taxes. The NHI is fund-       for-service system, providers
         beds, and relatively long lengths                  Taiwan                   ed by yearly income-adjusted pre-     respond by increasing the volume
         of stay. The Swiss have recently         Taiwan has never had pri-          miums. The payment of the             of services provided—leading to
         started experimenting with global  vate, commercial insurers and            premium is divided among              unnecessary services and improp-
         budgets and condition-based pay-   serves as another example of a           employers, government, and the        er care. Furthermore, providers
         ments as a method of controlling   universal healthcare system that         family. By law, administrative        are permitted to resell medica-
                                            was crafted to meet the cultural         overhead is kept at 3.5 percent of    tions directly to patients at a prof-
                                            expectations of a specific country.      the total budget (vs. 10 to 15 per-   it, leading to improper overmed-
              Single payer is not                 In 1995 Taiwan implemented         cent for private US insurers and      ication. Raising the fee schedule
                                            its National Health Insurance            2 percent for U.S. Medicare).         has been proposed. But politi-
               the only path to             (NHI) program, a universal, single             Through the NHI, Taiwan
                accomplishing               payer health insurance system.           implemented an open-ended, fee-
                                                                                                                            The challenges of the
                                            The goal of the NHI was to pro-          for-service system. The healthcare
              universal coverage.           vide unrestricted access to health-      delivery system consists of pub-       Taiwanese system are
                                            care for all Taiwanese regardless of     licly and privately (86 percent)
         hospital expenses.                 ability to pay. Prior to 1995, health-   owned hospitals. Physicians in            well known to all
               Pharmaceuticals are part of  care in Taiwan was financed              Taiwan are either paid on salary           government run
         the basic package. About a third   through ten different public insur-      or are self-employed owners of
         of all medications are covered     ance programs that each covered a        their own practices. Providers in     fee-for-service systems,
         with only a 10% co-insurance.      specific sector of the population        Taiwan have three main sources of        including Medicare
         The rest of medications are paid (such as farmers or government             revenue: fee-for-service payment
         for in full by patients or by sup- employees or the poor). Under this       from the NHI based on a national        in the United States.
         plemental insurance. Only recent- system, 41 percent of the popula-         fee schedule; patient co-pay-
         ly has there emerged a drive to    tion was uninsured (compared to          ments; and the direct sale to         cians cannot turn to the public
         control drug spending through      an uninsured rate of 15 percent in       patients of products and services     and ask for increased funding to
         the use of generic medications.    the United States today).                not covered by the NHI.               raise fees in the face of wide-
               Given the system of open-          Under growing political and              Cost sharing consists of        spread reports of waste and poor
         ended, fee-for-service healthcare, public pressure, the governing           the equivalent of co-payments         quality. The NHI has responded
         Switzerland faces the familiar     Nationalist Party initiated a plan-      applied for each component of         to troublesome deficits by adjust-
         problem of spiraling healthcare    ning program for national health         the services (physician care, hos-    ing the levers at its disposal: by
         spending. Swiss health policy      insurance that lasted from 1986 to       pital care, etc). These are waived    increasing premiums, increasing

         30                                                                                                                                          Fall 2004
                                                                      Oregon’s Future
                                                                                                                                                      FORU M

co-payments and implementing         insurance system is built on the      covered by retirement funds.        spends per capita on healthcare
global budgets.                      communitarian concept of solidari-    There are no deductibles and co- and dedicating 10.7% of its gross
      The NHI has started experi-    ty meaning that everyone, regard-     pays are minimal and are waived     domestic product to healthcare.
menting with incentive-based         less of class, uses and shares the    for the poor and those with chron-
payment such as its fee-for-out-     same health system. At the same       ic illnesses. Total out-of-pocket
come program in which providers      time, Germany preserves its plu-      payments are not permitted to
are reimbursed for meeting           ralistic roots by maintaining a       exceed 2% of an individual’s
process and outcomes goals for       decentralized system with insur-      annual income.
five major diseases. NHI has also    ance and healthcare delivery oper-           The healthcare delivery sys-
implemented an innovative                                                  tem is mainly private. Ambulatory
advance in Health Information
Technology. Residents will
                                         In 1883, Germany                  physicians join regional physician
                                                                           associations, which receive a glob-
receive a national heath card used   became the first country              al budget from sickness funds
to access an electronic medical
record that contains all personal
                                     in the world to mandate               within their region. The physician
                                                                           association pays ambulatory physi-
health information and acts as a         health insurance.                 cians fee-for-service based on a
communication tool between                                                 uniform fee schedule. The fees        Albert DiPiero, MD, MPH
providers, the NHI and patients.    ated at the regional level within      may be reduced through the year       Co-Director, HealthOregon
      The challenges of the         standards set at the national level.   if necessary to stay within the       adipiero@healthoregon.net
Taiwanese system are well known          Insurance is provided             global budget. Hospital physicians    Dr. DiPiero is the Co-Chair of
to all government run fee-for-ser-  through independent, nonprofit,        are salaried and are paid from the    HealthOregon, a public service
vice systems, including Medicare    regulated, “sickness funds” based      per diem payment made from            organization devoted to developing
in the United States. However,      on an individual’s place of            sickness funds to the hospital.       a modern healthcare system in
policy advisors consider Taiwan’s   employment or region. Each sick-              Like all other systems, the    Oregon. He also serves an
experiment as an interesting        ness fund is governed jointly by       German system has struggled with Adjunct Assistant Professor in
model. Taiwan provides an exam-     employers and employees. The           cost containment. Over the past       the Department of Medicine
ple of the rapid scope of change    sickness funds are financed by         few years it has addressed escalat-    at Oregon Health Sciences
that is possible within an econom-  required employer and employee-        ing costs by implementing global      University. He is a co-founder of
ically advanced society when        contributions through a payroll        budgets for ambulatory care,          Salu and of MyHealthBank which
political and cultural forces come  tax, with each contributing an         regional spending caps for phar-      are venture capital backed health
together. Despite inflation driven  average of around 7% of wages.         maceuticals and condition-related     information technology companies.
by over-utilization of the               Since 1993, individuals are       payments for hospitals. In addi-      Dr. DiPiero is a graduate of the
Taiwanese system, national          allowed to choose among sickness       tion, Germany has come late to        University of California, San
healthcare spending on universal    funds, which compete for mem-          the evidence-based medicine           Francisco School of Medicine,
care has risen modestly and         bers. Ninety-two percent of            quality movement. Providers have      where he also completed his
accounts for only 6.02 percent of   Germans are insured through            had exceptional autonomy and          internal medicine training.
gross domestic product (compared    sickness funds. About 8% are           only now are the quality of care
to 14% in the USA in 2001).         insured privately or are wealthy       and the variations in services
                                    enough to forgo insurance. And         being scrutinized with regard to
             Germany                about 7% of those covered by           effects on cost and safety. Other
      Germany has a national        national health insurance sickness     critical complaints include the
health insurance system that        funds also purchase private insur-     realization that the large number
achieves universal coverage with ance to cover amenities.                  of sickness funds add administra-
coexisting private insurance and         Even though sickness funds        tive overhead that is greater than
private sector providers.           are employment-based, the insur-       other systems with national health
      In 1883, Germany became       ance is fully portable. If a person    insurance. Yet, Germany remains
the first country in the world to   looses his job, the individual and
mandate health insurance. It start- family retain membership in the
ed with one segment of workers      sickness fund with no change in
                                                                           a visible reminder of a system
                                                                           with multiple insurers and private
                                                                           sector providers that manages to
                                                                                                                       VOTE !
and slowly expanded to mandate benefits. Retirees also remain cov-         provide healthcare coverage to its
coverage for the entire population. ered by their sickness fund, with a    entire population while spending
The German national health          portion of healthcare expenses         57% of what the United States

Fall 2004                                                                                                                                        31
                                                            Oregon’s Future
FORU M   Healthcare
                                                       Canada                       United Kingdom France                                     Switzerland                    Taiwan                       Germany
                                                      Universal lifetime coverage   Universal, free              Universal mandatory          Universal                      Universal lifetime           Universal coverage via
                                                      via the individual’s          lifetime health care         coverage via National        Compulsory Basic               coverage via National        mandatory enrollment in
                                                      provincial health plan        paid for by the NHS          Health Insurance             Social Insurance               Health Insurance             “sickness funds.” Some
                             Government               Provincial health plans       National Health Service      National Health Insurance    NONE (Regulated non-           Government run,              NONE (Regulated non-
                                                      act as single payer in each   available to all residents   Funds based on               profit or private for profit   single payer National        profit or private for profit
                                                      Province                                                   occupational status          insurance mandatory for        Health Insurance             insurance mandatory for
                                                                                                                                              all citizens)                                               all citizens)
                             Private                  Prohibited except for         Co-existing private          Supplemental private         Regulated, non-profit          Prohibited Independent,      Independent, nonprofit,
                                                      amenities                     insurance permitted          insurance to cover           social insurance funds         nonprofit, regulated         regulated “sickness funds”

                                                                                                                 amenities                    provide Compulsory             “sickness funds”             mandatory for most
                                                                                                                                              Basic Social Insurance         mandatory for most           Germans.
                                                                                                                                              as well as voluntary
                                                                                                                                              supplemental insurance                                      People above a certain
                                                                                                                                                                                                          income threshold may opt
                                                                                                                                              Regulated, private, for                                     out of sickness funds and
                                                                                                                                              profit insurers also offer                                  buy private insurance.
                                                                                                                                              the basic package and
                                                                                                                                              supplemental insurance
                                                      Transfers from federal        National tax financing       Employer and employee        Federal, cantonal and local    National taxes plus          Employer and

                                                      government and                                             payroll taxes, a general     taxes; individual premiums     income-adjusted              employee payroll
                                                      Provincial general funds                                   tax on all earnings, and     (subsidized based on           premium                      taxes
                                                                                                                 special taxes                means-testing), and
                                                                                                                                              patient co-pays
                             Physicians               Private & independent         Specialists are salaried     Independent solo             Private office-based           Self-employed owners         Private ambulatory
          Delivery System

                                                                                    employees of NHS, but        practitioners, private group physicians; hospital           of their own practices       physicians
                                                                                    may also do private work     practices, health centers, based physicians are             or salaried employees        Hospital physicians
                                                                                    on the side. Ambulatory      and hospital based           salaried employees             of hospitals                 are employees of
                                                                                    physicians are general       physicians.                  of the hospital
                                                                                    practitioners who are
                                                                                    independent contrators
                             Hospitals                Private and Public            Public NHS hospitals         Private, proprietary,        Public or private, for-        Public and private           Public and priate
                                                                                    or private hospitals         and public                   profit and nonprofit
                             Physician                Fee-for-service based on      Specialist - Salaried        Outpatient physicians        Office-based physicians        Self-employed physicians     Ambulatory physicians are
          Provider Payment

                                                      a Provincial fee schedule                                  paid fee-for-service         are paid fee-for-service.      paid fee-for-service based   paid fee-for serivce, based
                                                                                    Primary Care - Salaried      based on a national fee      Hospital physicians            on a national fee schedule   on uniform fee schedule,
                                                                                    or Capitated                 schedule set by the          are salaried                   set by the Government.       from a budget of their
                                                                                                                 Government                                                  Physicians supplement        regional physician asssoc-
                                                                                                                                                                             income through the direct    iation. Hospital physicians
                                                                                                                                                                             sale of medications          are salaried
                             Hospital                 Global budget                 Negotiated contracts         Per diem for private         Per diems or global            Global Budgets               Diagnosis-related
                                                                                    with local Primary           hospitals; Global budgets    budgets depending                                           groups system
                                                                                    Care Trusts                  for public hospitals         on the Canton
                             Hospital                 Yes                           Yes                          Yes                          Yes                            Yes                          Yes
                             Outpatient               Yes                           Yes                          Yes                          Yes                            Yes                          Yes
                             Drugs                    Varies between                Yes                          Yes                          Yes, but only for those        Yes                          Yes
                                                      provinces                                                                               on formulary
                             Dental                   Limited and varies            Yes                          Yes                          Yes, limited                   Yes                          Yes
                                                      between provinces
                             Home care                Limited and varies            Yes                          Yes                          Yes                            Yes                          Yes
                                                      between provinces
                             Complementary and        Unknown                       Unknown                      Yes                          Yes                            Yes                          Yes
                             Alternative Medicine
                             Cost sharing             None; free care for           None; free care within       Coinsurance with             Coinsurance with               Copays which are             Minimal copays.

                                                      anyone with a provincal       NHS                          exemptions for people        out-of-pocket limits           waived for major illnesses   Out-of-pocket expenses
                                                      health card                                                with chronic conditions      set by government              and preventive care          not to exceed 2% of
                                                                                                                                                                                                          annual income
                             Choice of providers      Full freedom of choice      Reforms are moving             Full freedom of choice       Full freedom of choice         Full freedom of physicians   Full freedom of physicians
                                                      of providers, hospitals     toward a greater consumer      of providers and hospitals   of providers and hospitals.    and hospitals                and hospitals
                                                      within a Province           choice. Patients have choice                                Compulsory insurance
                                                                                  of general practitioner.                                    pays only for those
                                                                                  Hospital choice permitted                                   hospitals on an approved
                                                                                  if wait for elective pro-                                   list in each Canton.
                                                                                  cedures exceeds 6 months
                             Cost control methods Mandatory global budgets National budget, fee-                 National fee schedule and    National fee schedule;         National fee schedules       National Fee-schedules
                                                     for hospital/health regions, schedules and salaries         hospital global budgets      Canton budgeting               and global budgets           based on global budgets
                                                     negotiated fee schedules     and queuing
                                                     for health care providers,
                                                     formularies for drugs,
                                                     and limits on the
                                                     diffusion of technology
                             Health spending         9.7%                         7.6%                           9.5%                         11.1%                          6%                           10.7%
          System Costs

                             as % of GDP
                             Per capita total health 57%                          41%                            52%                          68%                            15.7%                        57%
                             spending as % of US
                             per capita spending

         32                                                                                                                                                                                                               Fall 2004
                                                                                                             Oregon’s Future

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